Anthem clinical criteria and prior authorization updates for specialty pharmacy are available*

Prior authorization updates

 

Effective for dates of service on and after February 1, 2020, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.

 

Please note, inclusion of NDC code on your claim will shorten the claim processing time of drugs billed with a Not Otherwise Classified (NOC) code.

 

To access the clinical criteria document information please click here.  

 

Prior authorization clinical review of non-oncology specialty pharmacy drugs listed below is managed by Anthem’s medical specialty drug review team.

 

Clinical Criteria	HCPCS or CPT Code(s)	Drug
ING-CC-0072	Q5118	Zirabev
ING-CC-0075	Q5115	Truxima
ING-CC-0075	J3490	Ruxience

 

Review of specialty pharmacy drugs for oncology indications listed below is managed by AIM Specialty Health_® (AIM), a separate company.

 

Clinical Criteria	HCPCS or CPT Code(s)	Drug
ING-CC-0107	Q5118	Zirabev
ING-CC-0142*	J1930	Somatuline Depot
ING-CC-0143	C9399 J9999	Polivy
ING-CC-0144	J9313	Lumoxiti
ING-CC-0145	J9119	Libtayo

 * Non-oncology use is managed by Anthem’s medical specialty drug review team. Oncology use is managed by AIM.

Clinical criteria updates

 

Effective for dates of service on and after February 1, 2020, the following current clinical criteria documents were revised and might result in services that were previously covered but may now be found to be not medically necessary.

 

To access the clinical criteria document information please click here.  

Prior authorization clinical review of non-oncology specialty pharmacy drugs listed below is managed by Anthem’s medical specialty drug review team.

 

• ING-CC-0041 Complement Inhibitors Added medical necessity criteria for Soliris for the new indication of neuromyelitis optica spectrum disorder.

 

• ING-CC-0048 Spinraza (nusinersen) Updated medical necessity criteria for use after gene therapy to require decline in clinical status.

 

• ING-CC-0082 Onpattro (patisiran) Added not medically necessary criteria for combination use with other agents for amyloidosis.

 

Review of specialty pharmacy drugs for oncology indications listed below is managed by AIM Specialty Health_® (AIM), a separate company.

 

• ING-CC-0001 Erythropoiesis Stimulating Agents Reduced the timeframe for response for the use of Aranesp, Epogen and Procrit for anemia associated with myelosuppressive chemotherapy from 8-9 weeks to 8 weeks.

 

• ING-CC-0002 Colony Stimulating Factor Agents Removed medically necessary criteria for the prophylaxis of febrile neutropenia for Leukine.

 

• ING-CC-0106 Erbitux (cetuximab) Updated medical necessity criteria for RAS testing to require both KRAS and NRAS wild type.

 

Quantity limit updates

 

Effective January 31, 2020, clinical criteria document ING-CC-0136 Drug dosage, frequency, and route of administration will be archived.

 

Effective for dates of service on and after February 1, 2020, prior authorization clinical review of drug dosage, frequency and route of administration for the following specialty pharmacy codes from new or current clinical criteria will be based on the quantity limits established in the applicable clinical criteria document. The table below will assist you in identifying the applicable clinical criteria documents and corresponding HCPCS codes.

 

To access the clinical criteria document information please click here.  

 

Prior authorization clinical review of these specialty pharmacy drugs will be managed by Anthem’s medical specialty drug review team.

 

Clinical Criteria Document Number	Clinical Criteria Name	Drug(s)	HCPCS Code(s)
ING-CC-0001	Erythropoiesis Stimulating Agents	Aranesp, Epogen, Mircera, Procrit, Retacrit	J0881, J0882, J0885, J0887, J0888, Q4081, Q5105, Q5106
ING-CC-0003	Immunoglobulins	Asceniv, Bivigam, Carimune NF, Flebogamma DIF. Gammagard, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Octagam, Panzyga, Privigen	J1459, J1556, J1557, J1561, J1566, J1568, J1569, J1572, J1599
ING-CC-0007	Synagis (palivizumab)	Synagis	90378
ING-CC-0013	Mepsevii (vestronidase alfa)	Mepsevii	J3397
ING-CC-0018	Lumizyme (alglucosidase alfa)	Lumizyme	J0221
ING-CC-0021	Fabrazyme (agalsidase beta)	Fabrazyme	J0180
ING-CC-0022	Vimizim (elosulfase alfa)	Vimizim	J1322
ING-CC-0023	Naglazyme (galsulfase)	Naglazyme	J1458
ING-CC-0024	Elaprase (idursufase)	Elaprase	J1743
ING-CC-0025	Aldurazyme (laronidase)	Aldurazyme	J1931
ING-CC-0028	Benlysta (belimumab)	Benlysta	J0490
ING-CC-0031	Intravitreal Corticosteroid Implants	Illuvien, Retisert, Ozurdex, Yutiq	J7311, J7312, J7313, J7314
ING-CC-0032	Botulinum Toxin	Botox, Xeomin, Dysport, Myobloc	J0585, J0586, J0587, J0588
ING-CC-0033	Xolair (omalizumab)	Xolair	J2357
ING-CC-0034	Agents for Hereditary Angioedema	Cinryze, Haegarda, Berinert, Berinert, Firazyr, Ruconest, Kalbitor, Takhzyro	J0596, J0597, J0598, J1290, J1744, J0599, J0593
ING-CC-0041	Complement Inhibitors	Soliris, Ultomiris	J1300, J1303
ING-CC-0043	Monoclonal Antibodies to Interleukin-5	Cinqair, Fasenra, Nucala	J0517, J2182, J2786
ING-CC-0050	Monoclonal Antibodies to Interleukin-23	Tremfya, Ilumya	J1628, J3245
ING-CC-0051	Enzyme Replacement Therapy for Gaucher Disease	Cerezyme, Elelyso, Vpriv	J1786, J3060, J3385
ING-CC-0058	Octreotide Agents	Sandostatin, Sandostatin LAR Depot	J2353, J2354
ING-CC-0061	GnRH Analogs for the treatment of non-oncologic indications	Lupron Depot/Depot-Ped	J1950, J9217
ING-CC-0062	Tumor Necrosis Factor Antagonists	Simponi Aria, Remicade, Inflectra, Renflexis, Ixifi, Humira, Enbrel, Cimzia	J1602, J1745, Q5103, Q5104, Q5109, J0135, J1438, J0717
ING-CC-0063	Stelara (ustekinumab)	Stelara	J3357, J3358
ING-CC-0066	Monoclonal Antibodies to Interleukin-6	Actemra	J3262
ING-CC-0071	Entyvio (vedolizumab)	Entyvio	J3380
ING-CC-0072	Selective Vascular Endothelial Growth Factor (VEGF) Antagonists	Avastin, Lucentis, Eylea, Macugen, Zirabev, Mvasi	J2503, C9257, J9035, J2778, J0178, Q5118, Q5017
ING-CC-0073	Alpha-1 Proteinase Inhibitor Therapy	Aralast, Glassia, Prolastin-C, Zemaira	J0256, J0257
ING-CC-0075	Rituxan (rituximab) for Non-Oncologic Indications	Rituxan, Truxima	J9312, Q5115

 

* Notice of Material Changes/Amendments to Contract and Changes to Prior Authorization Requirements may apply for new or updated reimbursement policies, medical policies, or prior authorization requirements.